CHAPTER 3: AN ANALVSIS OF THE BUSINESS SECTORS
3.3 General Interventions 31
3.4.3 Role Modeling 36
Controversial or paradigm shifting policies are usually launched with special events and training. In the case of ground-breaking policies in South Africa, the press has been utilized to inform the general public of a company's stance and to effectively shift perceptions of the brand and company image.
In accordance with their policy, the DCSA voluntary testing campaign used every option available to reach as many people as possible. In addition to the usual media and in-house marketing options DCSA launched their VCT campaign with public testing of all senior company executives and all senior members of the National Union of Metalworkers in South Africa (NUMSA). On 22 May 2002 this united front against AIDS gathered at the DCSA plant in Swartkop and in full view of workers, the press corps and photographers, voluntarily took the HIV test. The statements made to the press were designed to encourage the DCSA workforce and all South Africans to get tested. It was also, indirectly, a challenge to other businesses. In keeping with their policy of holistic and practical follow up, DCSA simultaneously launched lucky draw competition for all workers, providing incentives to get tested.
The competition form served as an effective communications tool on several levels. The deadline for the competition lent urgency to the issues, while the graphics portraying the philosophy "see no evil, speak no evil, hear no evil"
placed HIV / AIDS firmly in the position of the enemy. It also strengthened the message of confidentiality and non-disclosure stated elsewhere in the text. The competition form was also inclusive in that it spoke to all three possible audiences: those who did not know their HIV status, those that had already confirmed their HIV positive status and more importantly, those who had confirmed their HIV negative status. It provided information about how and where to get tested, what to do if you were HIV positive and how to remain HIV negative while emphasizing the facilities of care and counseling available to DCSA workers. Comprehensive, but simply presented, the DCSA launch went a long way to changing worker perceptions of management and encouraging their voluntary testing.
3.4.4 Sustainability .
The sustainability of an HIV / AIDS policy is key to successful intervention.
Once off or random efforts do not change behavior. Companies must therefore have a policy that seeks to reinforce training, preventative and treatment interventions. DCSA has trained 132 peer educators to maintain the momentum of their initiatives. The costs of a workplace programme are high and sufficient funding must be set aside to implement the programme.
A multi-sectoral participatory process supports the sustainability of a workplace programme by creating a ripple effect into the workers family and community.
Companies can also help reduce the impact beyond employees by discussing their HIV AIDS policies with clients and suppliers and by sharing skills, resources and information. A bonus is that the company is also able establish their own credibility in a broader audience. This approach also supports other initiatives to change social norms and beliefs outside the work environment.
3.4.5 Evaluation
In evaluating the DCSA policy against best practice, it is clear that ILO guidelines were followed. This trend has continued in their monitoring and evaluation procedure. They have evaded the top down approach of prescribing policy to workers by engaging in social dialogues and debate with stakeholders.
Time, resources and dedicated human investment has been made to formulate a responsive policy. The DCSA policy is self-assessing by nature, with clear goals, associated tasks and deadlines. Measures of actual results in behavior change are recognized as part of a longer-term evaluation.
3.5 CONDOM USE AND DISTRIBUTION
The distribution of condoms has been adopted as a national strategy in South Africa. Implemented by government and civil society in high profile media campaigns, condom distribution is recognized as a quick, cheap and effective immediate term intervention. While the traditional use of condoms as a
contraceptive has to some extent supported these campaigns, it has not been easy to drive home the message that condoms are necessary to save lives!
The purpose of condom distribution as an intervention must meeUhe needs of its target audience. There is very little point in issuing condoms to a workforce that has already been determined to be predominantly HIV positive, unless distribution is accompanied by education that emphasizes the need to protect one's sexual partners. In most instances condoms are a preventative measure, vital to maintaining and HIV negative status.
3.5.1 Effectiveness as an Intervention
The only effective way to limit the spread of HIV is through a behavior change.
Getting everyone to make the change to condom use, although not simple, can be achieved through strategically planned projects that influence healthy behavior. Planning and implementing condom distribution and usage as an intervention requires an assessment of current behaviour. As a measurable intervention, practical and ongoing review of condom usage is more easily possible. Some companies have already used KAPB studies to establish baseline condom usage behavior, making future results easier to establish.
There appears to be general acceptance that used properly and consistently, condoms are one of the leading methods of protection against HIV. There is however, a range of obstacles hindering the effective, consistent and widespread use of condoms. In some cases companies have implemented the intervention in an ad hoc manner by providing dispensing machines only, unsupported by training or communication. While this may serve the company's image in that it is perceived to be doing something in the fight against AIDS it does not result in any long-term behavior change.
The editorial of AIDS Analysis Africa, August 2002 reports that condom use nationally is still relatively low. Reasons cited range from perceived diminished pleasure during sexual intercourse to the stigma of promiscuity associated with condom usage. Distribution has little impact where there is resistance to the use of condoms. Despite scientific research that proves that condom usage does
prevent the spread of HIV and other sexually transmitted infections, religious, moral and ethical debates have perpetuated resistance to usage. In some cases, initial bad experiences, high costs and limited or indiscreet access points inhibit condom usage. These are all factors to be considered in the planning this intervention.
An effective condom distribution intervention should be accompanied by practical, demonstrative training on the use of condoms and empowerment training for women who still have to negotiate the use of condoms, beyond just carrying them. Some companies have focused their training on changing men's attitudes and behavior toward women, attempting to shift the cultural and traditional systems that encourage discrimination against and exploitation of women.
3.5.2 Proactive Promotion of Condom Usage
Social marketing has been accepted as the most effective strategy for condom promotion because it increases acceptability and dissipates negative judgments and embarrassment associated with condoms. The impact of this face-to-face interaction is that it promotes behavior change in the immediate term. David Whitehead Textiles adopted this strategy as it sought to effectively market the use of condoms to its workforce and associated community. With the support of the Department of Health staff, David Whitehead health and safety officers and newly appointed peer educators were trained to share information in the workplace and at community venues. The ongoing education process was sustained by the peer educators who met with staff and public, after working hours, in the various entertainment venues, even public toilets, to talk about prevention. They also targeted sex workers and their clients.
A theatre company together with staff developed a play about AIDS and condom usage, which was then dramatized at various venues. Meetings were held in every possible location including beer halls, school halls, nightclubs and theatres. The company doctor and personnel manager made a brief presentation at each meeting prior to the dramatization. Every meeting and performance allowed for a question and an'swer session. On exit, every person
attending was given a free copy of the comic book that had been developed to share accurate infor~ation and translated into various languages to meet the community's needs. Condoms were included in the package and people were informed that the company would be distributing free condoms.
In a supporting strategy, David Whitehead Textiles took to displaying the number of AIDS related deaths every month on a notice board outside the factory clinic and canteen. Potentially controversial, this move succeeded in making people realise that HIV / AIDS kills. A second play has since been developed by workers and is now performed in the community, on farms and even at local soccer matches. This strategy has proven to be sustainable and effective.
Each aspect of the programme is proactive, with a focus on getting the information 'out there'. The use of role-plays and comic books made the information about HIV / AIDS easier to share and understand. They also facilitated use of the local language and colloquial style that 'brought the issues home' to every individual.
3.5.3 Distributing Condoms
The issue of where condoms should be dispensed in the workplace is a source of some concerns. At David Whitehead Textiles, condom dispensers in the toilets ran out before the end of each month where they were open to abuse and wastage. They were also being distributed in a vacuum, without access to information or demonstrations. Moving the dispensers to the clinics rectified these problems.
Some companies have questioned if employees should pay even a nominal amount for condoms. The argument for this is that people tend to make better use of products that are paid for, and ensures that distribution is not abused in practical jokes and pranks. Most companies have chosen to distribute free condoms, not only because they are available from the South African government at no cost, but because economically stressed employees are more likely to use condoms if they are free. The key here is an effective
communication strategy that emphasizes the value of a condom as
a
life changing / saving device.Due to the national campaign, access to condoms in the community has improved during the past few years. All family health clinics, provincial hospitals and even private practitioners are distributing condoms free of charge and with minimal embarrassment. The literature overview indicates that where condoms are distributed with direct access, without judgement and in conjunction with information, they tend to be more effective than dispensing machines.
3.5.4 The Female Condom
In The Expanding Role of the Female Condom, Warren (2000:8) points out that with correct and consistent use, the female condom is as effective as any other barrier method and has practically no side effects. In a wide range of acceptability studies in over 35 countries the female condom was compared favourably to the male condom. It does not interrupt sexual activity, does not depend on the male erection, and feels more similar to unprotected sex.
Rau (2002:49) asserts that although the female condom is still fairly new and therefore more expensive and less accessible, companies can make them available to female workers at a subsidized cost. This would have to be accompanied by training that empowers women to negotiate their usage.
Female condoms have been readily accepted by women, indicating that women want to take responsibility for their sexual behavior and HIV status.
3.5.5 Evaluation
Evaluating this intervention by the number of condoms distributed is probably the easiest and most misleading method. The quantity of condoms distributed does not extrapolate to the number actually used. Nor does it indicate the necessary changes in behavior that make condom lIsage an effective barrier to further HIV infections.
David Whitehead Textiles evaluated their condom distribution campaign by comparing the distribution to rate of sexually transmitted infections (STI). They found that between 1989 and 1992 there was a sharp decrease of between 50% and 75% in'the number of STl's treated at the company clinics. They also found however that the average distribution of condoms was calculated at less than one per worker per month. This implied that factors other than condom usage were contributing to the lower incidence of STl's. AIDS information officers found that the accompanying education programme had resulted in men now staying with one partner instead of having several.
The success of the David Whitehead condom distribution campaign lies primarily in their proactive communication techniques and the combined management and employee participation.
3.6 TREATMENT AND TESTING
Treatment and testing as an intervention incorporates:
• Sexually Transmitted Infections
• Voluntary HIV Counseling and Testing
• HIV Treatment
This broad definition seeks to promote treatment and care, as well as prevention. This intervention has the capacity to address a full range of AIDS related issues including secondary infections.
3.6.1 Sexually Transmitted Infections
Rau (2002:55) identifies STI's as one of the most common health problems among workers. In many countries STI's feature as one of the top 5 reasons for medical consultations. Addressing STls as a workplace intervention has value in that the clinic can provide on-site treatment, counseling and education about prevention and management of STI's as they relate to HIV. Treatment interventions are also more immediate and effective, as they are usually one- on-one interactions.
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"Case Study: Public Private Partnerships in South Africa to control STI's and· HIV" Rau (2002:91) sites the example of a partnership between mining companies, trade unions, public health officials and civic organizations. Their goal was to reduce STI infections and the risk of HIV infection by targeting mineworkers and their sexual partners, including the women in the surrounding community. The pilot programme provided a preventative and curative service to both women and mineworkers, resulting in a reduced STI prevalence of between 70% to 85% in the women and at least 40% among the mineworkers.The data analysis suggested that HIV infection was half what it would have been without the STI clinics.
The merit of treatment and prevention in the workplace is that they provide a therapeutic interim intervention that can promote long-term behavior change.
3.6.2 Occupational Health Clinics
Unlike the other key interventions discussed in this chapter, occupational health clinics geared toward the treatment, counseling and testing of STls and HIV, require an upfront capital investment. Whether the STI treatment is provided on- site or by private medical practitioners, the cost of treatment should be covered as a company provided service. The benefit to the company is that it usually costs less than one day's wage and the worker remains productive. For example, the South African mining industry estimates that for every US$1 spent on prevention they save US$30 in production and labour costs.
It is vital that an on-site clinic be established in a non-threatening, easily accessible setting. Although labeling it an STI clinic has been standard practice, the ILO best practice term is occupational health clinic, indicating the availability of a variety of health services and reducing the threat of embarrassment and discrimination around this issue.
Best practice recommends that clinics be established with medically trained personnel, proper equipment and adequate supplies of medication. Treatment and voluntary HIV testing procedures should be well-defined and communicated to workers. The use of a reputable pathology laboratory, attention to detail and
counseling before, during and after testing is a pre-requisite. Where possible, wellness programme guidelines should be available for workers living with HIV.
Clinic professionals should also be able to refer employees to other agencies at the company expense.
Ideally, personnel in the clinics should be able to engage workers on a broad range of social issues with a clear understanding of the cultural, religious and gender dynamics of the community they serve. Companies face an ethical and moral dilemma and require proper procedures, accepted by workers, to inform and treat partners of employees.
The benefit of the occupational health clinic as an intervention is that it provides an opportunity to introduce broader issues such as secondary infections, discrimination and in the long term, protects the company against future losses.
High levels of leadership are required to set an example by using the clinics, primarily to prevent the perception of low quality service not fit for upper management.
All best practice guidelines consistently highlight the need for confidence in the services offered by on-site clinics. Issues of trust and confidentiality can and do dictate the success of STI clinics as an intervention. How the programme is communicated to employees in terms of both policy and intervention is vital.
The clinic must be seen to operate independently of management influence with a commitment to non-disclosure, even within the company.
Awareness of gender sensitivity raises the question of whether men and women workers should have separate clinics? Daimler Chrysler SA introduced separate facilities for the small group of female workers at each of their plants. This is not always possible or cost effective. The clinic therefore requires an adequate support system to meet the varying needs of the workforce.
3.6.3 Supporting Strategies
Where companies don't have the necessary resources to meet all the best practice requirements, the clinic can be supported by peer education, inclusion of HIV / AIDS awareness in the induction programmes and access to AIDS help agencies. Above all, the programme must offer assurance and understanding and work to remove fear of using the services offered. Companies can also create support structures in the form of onsite support groups for workers living with HIV, or encourage the use of external groups by offering paid time off or flexible work schedules. Rau (2002:57) cites the unique example of a Durban company that meets its workers traditional and cultural needs by paying for dietary counseling through a traditional herbalist.
3.6.4 HIV Treatment Strategies
A good example of best practice at work is once again found in the mining industry. Having accepted the high HIV prevalence in their industry and the impact of a loss of productivity on their forecast earnings, Anglo American took a policy decision to provide all employees with voluntary antiretroviral treatment.
Unique in it's size and scope with an estimated 30, 000 HIV infected employees, the projected costs of the programme at R8,700 per employee exceeds R26 million per annum. In addition the company offers treatment and care, voluntary testing and a wellness programme that includes home-based care.
In a clear statement of long term commitment, the Anglo American wellness programmes for HIV positive individuals takes the holistic view. It includes best practice requirements such as:
• understanding the disease
• encouraging a healthy lifestyle
• offering nutritional supplements / immune therapy
• preventing and treating opportunistic infections, especially TB
• providing access to appropriate, affordable and sustainable anti-retroviral therapy when clinically indicated
In conjunction, the company has embarked on a "destigmatization of the environment" programme to encourage workers to obtain an early diagnosis and to promote acceptance of those living with HIV. It goes further to assure workers that with proper care and treatment, they can LIVE with HIV. There are currently 32 ART delivery sites registered with 223 employees on treatment as of 7th April 2003.
Despite the almost prohibitive costs of the treatments, Anglo American management has reiterated their commitment to caring for their employees by ensuring the sustain ability of the programme by engaging in partnership with drug manufacturers and medical research companies.
In a similar move, the Gold Fields mining company implemented the health clinic intervention with a different strategic focus. With an estimated 72% of their workforce presently HIV negative, their focus is a prevention programme promoted with the message "Protect your HIV free status with your life". The programme requires every employee to attend at least one AIDS awareness programme with a view to encouraging workers to take charge of their own health and recognizes the responsibilities and rights of workers and management.
3.6.5 Evaluation
The nature of STI interventions and health clinics allow companies to broaden local level interventions to provide ongoing support of behavior changes in the entire community. They are also by nature, self-evaluating: if they are not being used or are under-utilised, companies need to review their implementation and communication strategy.
Clinic statistics provide more definite numbers to assess company risk while providing a testing site to monitor use of other interventions and their successes. Access to raw data is easier at a clinic. Simple monitoring of the number of visits and the incidents of infection and treatment compared to initial baseline data will provide a picture of the clinic's effectiveness. Counseling and meetings with clinic staff provide an in-depth understanding of the issues faced by. workers without compromising their' confidentiality. This too allows